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Marko Noc, University Medical Center, Ljubljana, Slovenia,
Bjørn Bendz, Rikshospitalet University Hospital, Oslo, Norway,
Karl B. Kern, University of Arizona Sarver Heart Center, Tucson, Arizona, USA
Coronary artery disease represents the most important cause of out-of-hospital cardiac arrest. Immediate coronary angiography in patients after reestablishment of spontaneous circulation demonstrated angiographic evidence of coronary artery disease in 80% of patients, with the majority (90%) having significant obstructive stenoses of one or more coronary arteries. Experimental animal models have shown that coronary obstructions have a profound effect on the utility of cardiopulmonary resuscitation to perfuse the myocardium during cardiac arrest. We found that coronary diameter stenoses as little as 33% decreased distal perfusion by more than half (see Chapter 18 for more details). Postmortem examinations of sudden cardiac death victims indicate that unstable plaque with associated coronary thrombosis may be documented in more than 80% of the cases. Accordingly, acute coronary thrombotic events leading to critical narrowing or complete coronary obstruction and possibly distal microembolization may be a main trigger of sudden arrhythmic cardiac arrest.
Current strategy for management of acute coronary syndromes
Acute coronary syndrome (ACS), based on 12-lead electrocardiogram, is traditionally divided into evolving ST segment elevation acute myocardial infarction (STEMI) and unstable angina/non-ST elevation myocardial infarction (UA/NSTEMI) (Fig. 42.1). More than 90% of the patients with STEMI have a complete thrombotic occlusion of the epicardial part of one of the coronary arteries without adequate collateral flow to the distal part of the affected artery. The mechanisms of coronary obstruction in patients with UA/NSTEMI are more heterogeneous.
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